New York Consumer Guide to Health Insurance Companies. New York State Andrew M. Cuomo, Governor

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1 New York Consumer Guide to Health Insurance Companies 2015 New York State Andrew M. Cuomo, Governor

2 Table of Contents ABOUT THIS GUIDE... 2 COMPLAINTS... 4 PROMPT PAY COMPLAINTS... 9 INTERNAL APPEALS EXTERNAL APPEALS GRIEVANCES ACCESS AND SERVICE CHILD AND ADOLESCENT HEALTH ADULT HEALTH WOMEN S HEALTH BEHAVIORAL HEALTH QUALITY OF PROVIDERS MANAGING MEDICATIONS HEALTH INSURANCE COMPANY ACCREDITATION HOW HEALTH INSURANCE COMPANIES PAY HEALTH CARE PROVIDERS OVERALL COMPLAINT RANKING TELEPHONE NUMBERS FOR HEALTH INSURANCE COMPANIES CONTACTS AND RESOURCES... 60

3 New York Consumer Guide to Health Insurance Companies and Plans 2 ABOUT THIS GUIDE The purpose of this Guide is to: Inform you of the health insurance products offered in New York State and how they work. Help you choose a health insurance company based on quality of care and service. DATA SOURCES The information in this Guide is provided by two New York agencies. 1. New York State Department of Financial Services (DFS) is responsible for protecting the public interest by supervising and regulating financial products and services, including those subject to the provisions of the Insurance Law and the Banking Law in New York State. DFS compiles the complaint and appeal information that appears on pages 4 23 and the grievance information that appears on pages DFS data are from calendar year New York State Department of Health (DOH) works to protect and promote the health of New Yorkers through prevention, research and by ensuring delivery of quality health care. DOH compiles its portion of the complaint data on page 5 and the information on health insurance company performance that appears on pages DOH collects data through the New York State Department of Health s Quality Assurance Reporting Requirements (QARR) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS ). 1 DOH data on quality of care and service for health insurance companies are from calendar year 2013, except where noted. DETAILS ABOUT THE DATA The Guide does not include: HMOs with less than $25 million in premiums or fewer than 5,000 members. Commercial and EPO/PPO plans with less than $50 million in premiums. Data for Medicare, Medicaid or self-insured plans. 2 Health insurance companies are listed alphabetically in the data tables, except for the Overall Complaint Ranking table on pages Some health insurance companies are listed using different names depending on whether the data are reported by DFS or DOH. 1 CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 2 For information about Medicare coverage, call the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees this program, at 800-MEDICARE ( ), or visit the website at You can also contact the New York State Office for the Aging Health Insurance Information Counseling & Assistance Program (HIICAP) by calling , or by visiting the website at For information on New York s Medicaid program, contact your local county Department of Social Services.

4 New York Consumer Guide to Health Insurance Companies and Plans 3 HEALTH INSURANCE COMPANY AND PLAN DEFINITIONS Health Maintenance Organization (HMO) Plan: A type of coverage that provides comprehensive health services to members in return for a monthly premium and copayment. In an HMO plan, members choose an in-network primary care physician (PCP) who coordinates each assigned member s care. Members need a referral from their PCP to obtain services from in-network specialists and provider services. Although many HMOs require their members to go to doctors and other providers in the HMO provider network, some HMO plans offer the option to go out-of-network (for example in a HMO Point of Service (POS) plan). Unless a member has an HMO Plan that offers an out-ofnetwork option, out-of-network services are usually not covered. Exclusive Provider Organization (EPO) Plan: A type of coverage in which the insurer contracts with doctors, hospitals and other types of providers to form a network of providers. Certain services may require pre-authorization. In an EPO, members must use the providers who belong to the EPO network or their expenses will not be covered. Preferred Provider Organization (PPO) Plan: A type of managed care coverage based on a network of doctors and hospitals that provides care to an enrolled population at a prearranged discounted rate. PPO members do not usually need a referral to see a specialist, but certain services may require pre-authorization from the health insurance company. PPO members may use out-of-network providers however, members usually pay more when they receive care outside the PPO network. Commercial Insurers: Health insurance can also be written by life insurers, property/casualty insurers and other types of insurers. Commercial insurers employ managed care strategies but offer a more traditional approach to coverage than HMOs. Policyholders are subject to deductibles and significant out-of-pocket costs unless they use a preferred provider network.

5 4 Complaints Each year, the New York State DFS and DOH receives complaints from consumers and health care providers about health insurance companies. Complaints typically involve issues related to prompt payment, reimbursement, coverage, benefits, rates and premiums. After reviewing each complaint, the State determines if the health insurance company acted appropriately. If the State determines that the health insurance company did not act in accordance with its statutory and contractual obligations, the company must resolve the problem to come into compliance. For issues concerning payment, reimbursement, coverage, benefits, rates and premiums, contact DFS at: or call UNDERSTANDING THE CHARTS Rank: Each health insurance company s rank is based on how many complaints were resolved by DFS in favor of the member or provider, relative to the company s premiums. A lower number results in a higher ranking. If the ratios are the same, the health insurance company with the higher premiums is ranked higher. Total Complaints to DFS: Total number of complaints closed by DFS in Large health insurance companies may receive more complaints because they have more members than smaller health insurance companies. Complaints Upheld by DFS: Number of closed complaints resolved in favor of the member or provider because DFS determined that the health insurance company did not comply with statutory or contractual obligations. Complaints upheld by DFS are used to calculate the complaint ratio and ranking. Premiums: Dollar amount generated by a health insurance company in New York State during Premiums are used to calculate the complaint ratio so that health insurance companies of different sizes can be compared fairly. Premium data exclude Medicare and Medicaid. Complaint Ratio: Number of complaints upheld (complaints resolved in favor of the member or provider) by DFS, divided by the health insurance company s premiums. Total Complaints to DOH: Total number of complaints closed by DOH. Complaints to DOH involve concerns about the quality of care received by members. Complaints Upheld by DOH: Number of complaints closed by DOH that were decided in favor of the member or provider.

6 5 Complaints HMOs 2014 Data Source: DFS and DOH Data Compiled by the New York State DFS Data Compiled by the New York State DOH HMO Rank 1 1 = Best 10 = Worst Total Complaints to DFS Complaints Upheld by DFS Premiums (Millions $) Complaint Ratio Total Complaints to DOH Complaints Upheld by DOH Aetna Health Inc Capital District Physicians Health Plan Community Blue (HealthNow) Empire HealthChoice HMO, Inc Excellus Health Plan HIP Health Maintenance Organization , Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans (NY), Inc , UnitedHealthcare of New York, Inc HMOs with a lower complaint ratio receive a higher ranking. 2Plan intends to withdraw from New York s individual health insurance market effective December 31, Total 1, ,

7 6 Complaints EPO/PPO Health Plans Data Source: DFS EPO/PPO Health Plan Rank 2,3 1 = Best 12 = Worst Total Complaints to DFS Complaints Upheld by DFS Premiums (Millions $) Complaint Ratio CDPHP Universal Benefits, Inc Empire HealthChoice Assurance, Inc , Excellus Health Plan, Inc , Group Health Incorporated , Health Republic Insurance of New York, Corp HealthNow New York Inc , HIP Insurance Company of New York Independent Health Benefits Corporation MVP Health Insurance Company Oscar Insurance Corporation Oxford Health Insurance, Inc , UnitedHealthcare Insurance Company of New York , Total 2, , The non-profit indemnity category was removed and replaced with an EPO/PPO category to better reflect the types of policies currently being issued. The EPO/PPO category includes plans previously in the non-profit indemnity category and some plans previously in the commercial category that offer an EPO or PPO product. 2If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 3Health insurance companies with a lower complaint ratio receive a higher ranking. 4Complaints, complaint ratios, and premiums include data from the health insurance company's EPO, PPO and commercial business.

8 7 Complaints Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company Rank 1,2 1 = Best 35 = Worst Total Complaints to DFS Complaints Upheld by DFS Premiums (Millions $) Complaint Ratio Aetna Life Insurance Company 3, , American Family Life Assurance Company of New York American Progressive Life and Health Insurance BCS Insurance Company Berkshire Life Insurance Company of America CIGNA Health and Life Insurance Company , CIGNA Life Insurance Company of New York Combined Life Insurance Company of New York Delta Dental of New York, Inc Dentcare Delivery Systems, Inc Eastern Vision Service Plan, Inc First Unum Life Insurance Company Genworth Life Insurance Company of New York Guardian Life Insurance Company of America Hartford Life Insurance Company HM Life Insurance Company of New York John Hancock Life & Health Insurance Company Liberty Life Assurance Company of Boston If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 2Health insurance companies with a lower complaint ratio receive a higher ranking. 3Complaints, complaint ratios, and premiums include data from the health insurance company's EPO, PPO and commercial business. 4Plan intends to withdraw from New York s individual health insurance market effective December 31, Plan issues dental coverage only. 6Plan issues vision coverage only.

9 8 Complaints Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company Rank 1,2 1 = Best 35 = Worst Total Complaints to DFS Complaints Upheld by DFS Premiums (Millions $) Complaint Ratio Lincoln Life & Annuity Company of New York Massachusetts Mutual Life Insurance Company Metropolitan Life Insurance Company MVP Health Services Corporation National Union Fire Insurance Company of Pittsburgh, PA New York Life Insurance Company Nippon Life Insurance Company of America Northwestern Mutual Life Insurance Company Paul Revere Life Insurance Company Principal Life Insurance Company Prudential Insurance Company of America ShelterPoint Life Insurance Company Standard Life Insurance Company of New York Standard Security Life Insurance Company of New York Sun Life and Health Insurance Company Transamerica Financial Life Insurance Company United States Fire Insurance Company Total , If ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 2Health insurance companies with a lower complaint ratio receive a higher ranking. 3Plan issues dental coverage only.

10 9 Prompt Pay Complaints New York State requires all health insurance companies to: Pay undisputed electronic claims within 30 days and pay undisputed paper claims within 45 days of receipt, or Request all additional information from the member or the provider, if necessary, within 30 days of receipt of the claim, or Deny the claim within 30 days of receipt. For issues concerning payment, reimbursement, coverage, benefits, rates and premiums, contact DFS at: or call UNDERSTANDING THE CHARTS Rank: Each health insurance company s rank is based on the number of prompt pay complaints upheld, relative to the company s premiums. A lower number results in a higher ranking. If the ratios are the same, the health insurance company with the higher premiums is ranked higher. Total Complaints: Total number of complaints closed by DFS in Complaints typically involve issues about prompt payment, reimbursement, coverage, benefits, rates and premiums. Total Prompt Pay Complaints: Total number of prompt pay complaints closed by DFS in Large health insurance companies may receive more complaints because they have more members and pay more claims than smaller health insurance companies. Prompt Pay Complaints Upheld: Number of closed prompt pay complaints where DFS determined that the health insurance company was not processing claims in a timely manner. Prompt pay complaints upheld by DFS are used to calculate the prompt pay complaint ratio and ranking. Premiums: Dollar amount generated by a health insurance company in New York State in Premiums are used to calculate the prompt pay complaint ratio so that health insurance companies of different sizes can be compared fairly. Premium data exclude Medicare and Medicaid. Prompt Pay Complaint Ratio: Number of prompt pay complaints upheld divided by a health insurance company s premiums.

11 10 Prompt Pay Complaints HMOs 2014 Data Source: DFS HMO Rank 1,2 1 = Best 10 = Worst Total Complaints Total Prompt Pay Complaints Prompt Pay Complaints Upheld Premiums (Millions $) Prompt Pay Complaint Ratio Aetna Health Inc Capital District Physicians Health Plan Community Blue (Healthnow) Empire HealthChoice HMO, Inc Excellus Health Plan HIP Health Maintenance Organization , Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans (NY), Inc , UnitedHealthcare of New York, Inc If the ratios are the same among HMOs, the HMO with the higher premium amount receives a higher ranking. 2HMOs with a lower complaint ratio receive a higher ranking. 3Plan intends to withdraw from New York s individual health insurance market effective December 31, Total 1, ,

12 11 Prompt Pay Complaints EPO/PPO Health Plans Data Source: DFS EPO/PPO Health Plan Rank 2,3 1 = Best 12 = Worst Total Complaints Total Prompt Pay Complaints Prompt Pay Complaints Upheld Premiums (Millions $) Prompt Pay Complaint Ratio CDPHP Universal Benefits, Inc Empire HealthChoice Assurance, Inc , Excellus Health Plan, Inc , Group Health Incorporated , Health Republic Insurance of New York, Corp HealthNow New York Inc , HIP Insurance Company of New York Independent Health Benefits Corporation MVP Health Insurance Company Oscar Insurance Corporation Oxford Health Insurance, Inc , UnitedHealthcare Insurance Company of New York , Total 2, , The non-profit indemnity category was removed and replaced with an EPO/PPO category to better reflect the types of policies currently being issued. The EPO/PPO category includes plans previously in the non-profit indemnity category and some plans previously in the commercial category that offer an EPO or PPO product. 2If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 3Health insurance companies with a lower complaint ratio receive a higher ranking. 4Complaints, complaint ratios, and premiums include data from the health insurance company's EPO, PPO and commercial business.

13 12 Prompt Pay Complaints Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company Rank 1,2 1 = Best 35 = Worst Total Complaints Total Prompt Pay Complaints Prompt Pay Complaints Upheld 1If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 2Health insurance companies with a lower complaint ratio receive a higher ranking. 3Complaints, complaint ratios, and premiums include data from the health insurance company's EPO, PPO and commercial business. 4Plan intends to withdraw from New York s individual health insurance market effective December 31, Plan issues dental coverage only. 6Plan issues vision coverage only. Premiums (Millions $) Prompt Pay Complaint Ratio Aetna Life Insurance Company 3, , American Family Life Assurance Company of New York American Progressive Life and Health Insurance BCS Insurance Company Berkshire Life Insurance Company of America CIGNA Health and Life Insurance Company , CIGNA Life Insurance Company of New York Combined Life Insurance Company of New York Delta Dental of New York, Inc Dentcare Delivery Systems, Inc Eastern Vision Service Plan, Inc First Unum Life Insurance Company Genworth Life Insurance Company of New York Guardian Life Insurance Company of America Hartford Life Insurance Company HM Life Insurance Company of New York John Hancock Life & Health Insurance Company Liberty Life Assurance Company of Boston

14 13 Prompt Pay Complaints Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company Rank 1,2 1 = Best 35 = Worst Total Complaints Total Prompt Pay Complaints Prompt Pay Complaints Upheld Premiums (Millions $) Prompt Pay Complaint Ratio Lincoln Life & Annuity Company of New York Massachusetts Mutual Life Insurance Company Metropolitan Life Insurance Company MVP Health Services Corporation National Union Fire Insurance Company of Pittsburgh, PA New York Life Insurance Company Nippon Life Insurance Company of America Northwestern Mutual Life Insurance Company Paul Revere Life Insurance Company Principal Life Insurance Company Prudential Insurance Company of America ShelterPoint Life Insurance Company Standard Life Insurance Company of New York Standard Security Life Insurance Company of New York Sun Life and Health Insurance Company Transamerica Financial Life Insurance Company United States Fire Insurance Company Total , If the ratios are the same among health insurance companies, the health insurance company with the higher annual premium amount receives a higher ranking. 2Health insurance companies with a lower complaint ratio receive a higher ranking. 3Plan issues dental coverage only.

15 Internal Appeals An internal appeal or utilization review (UR) occurs when a member or provider asks a health insurance company to reconsider its refusal to pay for a medical service that the health insurance company considers experimental, investigational, not medically necessary, a clinical trial, or a treatment for a rare disease. If you are an HMO member, you may also appeal when the HMO denies a request to pay for an out-of-network service 1 if the HMO offers an alternate service in-network. The right to appeal an out-of-network service denial is being expanded to other insurance policies on each policy s renewal date on or after March 31, This appeal right will apply to out-of-network service denials issued on or after the insurance policy s renewal date. Additionally, members have the right to appeal an out-of-network referral 2 denial issued on or after March 31, 2015 for HMO and Managed Care policies. For other policies, the right to appeal an out-of-network referral denial will be made available on each policy s renewal date on or after March 31, Health insurance companies are required to have appeals reviewed by medical professionals. Common internal appeals involve the medical necessity of hospital admissions, length of hospital stays and use of certain medical procedures. 14 UNDERSTANDING THE CHARTS Filed Appeals: Number of internal appeals submitted to the health insurance company by members or providers in Closed Appeals: Number of internal appeals that the health insurance company decided by the end of Reversals on Appeals: Number of closed internal appeals where the health insurance company decided in favor of members or providers. If a health insurance company s decision to deny payment or coverage is reversed on an internal appeal, the health insurance company agrees to pay for the service or procedure. Reversal Rate: Percentage of reversals on appeals divided by closed appeals. 1An out-of-network service denial is a pre-authorization request that is denied because the service is not available in-network and the health plan recommends an alternate in-network service that it believes is not materially different from the requested out-of-network service. KEEP IN MIND A health insurance consumer should pay specific attention to a health insurance company that has a very high or very low reversal rate. Please note: There is no ideal reversal rate. A low reversal rate may indicate that the health insurance company s initial decisions are correct, so fewer decisions require reversal, but an unusually low reversal rate may indicate that the health insurance company does not give appropriate reconsideration to initial decisions. A high reversal rate may indicate that a health insurance company s internal appeal process is responsive to members and providers, but an unusually high reversal rate may indicate that the health insurance company s process for making initial decisions is flawed. The number of internal appeals filed may be higher for health insurance companies that actively promote the appeal process and encourage members and providers to appeal denied services. 2An out-of-network referral denial occurs when the member s out-of-network referral request is denied because the health plan has an in-network provider with appropriate training and experience to meet the particular needs of the member.

16 15 Internal Appeals HMOs 2014 Data Source: DFS HMO Filed Appeals Closed Appeals 1 Reversals on Appeals Reversal Rate (Percentage) Aetna Health Inc % Capital District Physicians Health Plan % Community Blue (Healthnow) % Empire HealthChoice HMO, Inc. 1,364 1, % Excellus Health Plan % HIP Health Maintenance Organization % Independent Health Association, Inc % MVP Health Plan, Inc % Oxford Health Plans (NY), Inc. 1, % UnitedHealthcare of New York, Inc % Total 4,686 4,584 1, % 1Closed internal appeals can exceed filed internal appeals in 2014 because closed internal appeals also include internal appeals filed prior to Plan intends to withdraw from New York s individual health insurance market effective December 31, 2015.

17 16 Internal Appeals EPO/PPO Health Plans Data Source: DFS EPO/PPO Health Plan Filed Appeals Closed Appeals 2 Reversals on Appeals Reversal Rate (Percentage) CDPHP Universal Benefits, Inc % Empire HealthChoice Assurance, Inc. 3 4,525 4,780 1, % Excellus Health Plan, Inc. 3 2,654 2, % Group Health Incorporated 3 1,395 1, % Health Republic Insurance of New York, Corp % HealthNow New York Inc % HIP Insurance Company of New York % Independent Health Benefits Corporation % MVP Health Insurance Company % Oscar Insurance Corporation % Oxford Health Insurance, Inc. 3 4,511 4,511 2, % UnitedHealthcare Insurance Company of New York 3 3,908 3,908 1, % Total 18,653 18,818 7, % 1The non-profit indemnity category was removed and replaced with an EPO/PPO category to better reflect the types of policies currently being issued. The EPO/PPO category includes plans previously in the non-profit indemnity category and some plans previously in the commercial category that offer an EPO or PPO product. 2Closed internal appeals can exceed filed internal appeals in 2014 because closed internal appeals also include internal appeals filed prior to Appeals and reversal rates include data from the health insurance company's EPO, PPO and commercial business.

18 17 Internal Appeals Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Filed Appeals Closed Appeals 2 Reversals on Appeals Reversal Rate (Percentage) Aetna Life Insurance Company 3,4 2,416 2, % American Family Life Assurance Company of New York % American Progressive Life and Health Insurance % BCS Insurance Company % Berkshire Life Insurance Company of America % CIGNA Health and Life Insurance Company 3 2,514 2, % CIGNA Life Insurance Company of New York % Combined Life Insurance Company of New York % Delta Dental of New York, Inc % Dentcare Delivery Systems, Inc % Eastern Vision Service Plan, Inc % First Unum Life Insurance Company % Genworth Life Insurance Company of New York % Guardian Life Insurance Company of America 4,531 4,568 3, % Hartford Life Insurance Company % HM Life Insurance Company of New York % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no internal appeals. 2Closed internal appeals can exceed filed internal appeals in 2014 because closed internal appeals also include internal appeals filed prior to Appeals and reversal rates include data from the health insurance company's EPO, PPO and commercial business. 4Plan intends to withdraw from New York s individual health insurance market effective December 31, Plan issues dental coverage only. 6Plan issues vision coverage only.

19 18 Internal Appeals Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Filed Appeals Closed Appeals 2 Reversals on Appeals Reversal Rate (Percentage) John Hancock Life & Health Insurance Company % Liberty Life Assurance Company of Boston % Lincoln Life & Annuity Company of New York % Massachusetts Mutual Life Insurance Company % Metropolitan Life Insurance Company 12,028 12,028 10, % MVP Health Services Corporation % National Union Fire Insurance Company of Pittsburgh, PA % New York Life Insurance Company % Nippon Life Insurance Company of America % Northwestern Mutual Life Insurance Company % Paul Revere Life Insurance Company % Principal Life Insurance Company % Prudential Insurance Company of America % ShelterPoint Life Insurance Company % Standard Life Insurance Company of New York % Standard Security Life Insurance Company of New York % Sun Life and Health Insurance Company % Transamerica Financial Life Insurance Company % United States Fire Insurance Company % Total 21,938 21,911 15, % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no internal appeals. 2Closed internal appeals can exceed filed internal appeals in 2014 because closed internal appeals also include internal appeals filed prior to Plan issues dental coverage only.

20 External Appeals After an internal appeal, members and providers may request an external appeal when a health insurance company continues to refuse to pay for/provide reimbursement for health care services on the basis that services are experimental, investigational, not medically necessary, a clinical trial, or a treatment for a rare disease. If you are an HMO member, you may also appeal when the HMO denies a request to pay for an out-of-network service 1 if the HMO offers an alternate service in-network. The right to appeal an out-of-network service denial is being expanded to other insurance policies on each policy s renewal date on or after March 31, This appeal right will apply to out-of-network service denials issued on or after the insurance policy s renewal date. Additionally, members have the right to appeal an out-of-network referral 2 denial issued on or after March 31, 2015 for HMO and Managed Care policies. For other policies, the right to appeal an out-of-network referral denial will be made available on each policy s renewal date on or after March 31, Before requesting an external appeal, you usually must complete the health insurance company s first-level internal appeal process, or you and your health insurance company may agree jointly to waive the internal appeal process. *Providers may file external appeals on their own behalves for continued or extended health care services; additional services for a patient undergoing a course of continued treatment; or services already provided. UNDERSTANDING THE CHARTS 19 Total External Appeals: Total number of cases assigned to an external appeal organization in Reversals on External Appeals: Number of cases where an external appeal organization decided in favor of the member or provider. External Appeals Reversed in Part: Number of cases where an external appeal organization decided partially in favor of the member or provider. For example, an HMO refuses payment of a 5-day hospital stay, claiming it was not medically necessary; however, the external appeal organization decides that 3 of the 5 days were medically necessary. External Appeals Upheld: Number of cases where an external appeal organization agreed with the health insurance company s decision not to cover a service or procedure. Reversal Rate: Percentage of reversals on external appeals (cases decided in favor of the member or provider) divided by total external appeals. Please note that the number of cases when an external appeal organization decided partially in favor of the member or provider is also included in the reversal rate. A high reversal rate may indicate that a health insurance company does not make appropriate coverage decisions. 1An out-of-network service denial is a pre-authorization request that is denied because the service is not available in-network and the health plan recommends an alternate in-network service that it believes is not materially different from the requested out-of-network service. 2An out-of-network referral denial occurs when the member s out-of-network referral request is denied because the health plan has an in-network provider with appropriate training and experience to meet the particular needs of the member.

21 20 External Appeals HMOs 2014 Data Source: DFS HMO Total External Appeals Reversals on External Appeals External Appeals Reversed in Part External Appeals Upheld Reversal Rate (Percentage) 1 Aetna Health Inc % Capital District Physicians Health Plan % Community Blue (HealthNow) % Empire HealthChoice HMO, Inc % Excellus Health Plan % HIP Health Maintenance Organization % Independent Health Association, Inc % MVP Health Plan, Inc % Oxford Health Plans (NY), Inc % UnitedHealthcare of New York, Inc % Total % 1Rate includes reversed-in-part decisions. 2Plan intends to withdraw from New York s individual health insurance market effective December 31, 2015.

22 21 External Appeals EPO/PPO Health Plans Data Source: DFS EPO/PPO Health Plan Total External Appeals Reversals on External Appeals External Appeals Reversed in Part External Appeals Upheld Reversal Rate (Percentage) 2 CDPHP Universal Benefits, Inc % Empire HealthChoice Assurance, Inc % Excellus Health Plan, Inc % Group Health Incorporated % Health Republic Insurance of New York, Corp % HealthNow New York Inc % HIP Insurance Company of New York % Independent Health Benefits Corporation % MVP Health Insurance Company % Oscar Insurance Corporation % Oxford Health Insurance, Inc % UnitedHealthcare Insurance Company of New York % Total 1, % 1The non-profit indemnity category was removed and replaced with an EPO/PPO category to better reflect the types of policies currently being issued. The EPO/PPO category includes plans previously in the non-profit indemnity category and some plans previously in the commercial category that offer an EPO or PPO product. 2Rate includes reversed-in-part decisions. 3External Appeals and reversal rates include data from the health insurance company's EPO, PPO and commercial business.

23 22 External Appeals Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Total External Appeals Reversals on External Appeals External Appeals Reversed in Part External Appeals Upheld Reversal Rate (Percentage) 2 Aetna Life Insurance Company 3, % American Family Life Assurance Company of New York % American Progressive Life and Health Insurance % BCS Insurance Company % Berkshire Life Insurance Company of America % CIGNA Health and Life Insurance Company % CIGNA Life Insurance Company of New York % Combined Life Insurance Company of New York % Delta Dental of New York, Inc % Dentcare Delivery Systems, Inc % Eastern Vision Service Plan, Inc % First Unum Life Insurance Company % Genworth Life Insurance Company of New York % Guardian Life Insurance Company of America % Hartford Life Insurance Company % HM Life Insurance Company of New York % John Hancock Life & Health Insurance Company % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no external appeals. 2Rate includes reversed-in-part decisions. 3External Appeals and reversal rates include data from the health insurance company's EPO, PPO and commercial business. 4Plan intends to withdraw from New York s individual health insurance market effective December 31, Plan issues dental coverage only. 6Plan issues vision coverage only.

24 23 External Appeals Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Total External Appeals Reversals on External Appeals External Appeals Reversed in Part External Appeals Upheld Reversal Rate (Percentage) 2 Liberty Life Assurance Company of Boston % Lincoln Life & Annuity Company of New York % Massachusetts Mutual Life Insurance Company % Metropolitan Life Insurance Company % MVP Health Services Corporation % National Union Fire Insurance Company of Pittsburgh, PA % New York Life Insurance Company % Nippon Life Insurance Company of America % Northwestern Mutual Life Insurance Company % Paul Revere Life Insurance Company % Principal Life Insurance Company % Prudential Insurance Company of America % ShelterPoint Life Insurance Company % Standard Life Insurance Company of New York % Standard Security Life Insurance Company of New York % Sun Life and Health Insurance Company % Transamerica Financial Life Insurance Company % United States Fire Insurance Company % Total % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no external appeals. 2Rate includes reversed-in-part decisions. 3Plan issues dental coverage only.

25 24 Grievances A grievance is a complaint by a member or provider to a health insurance company about a denial based on limitations or exclusions in the contract. Medical necessity issues are the subjects of internal appeals, not grievances. Common grievances include problems getting referrals to specialists and disagreements over benefit coverage. According to New York State law, health insurance companies that offer a comprehensive policy that uses a network of providers must have a system in place for responding to members concerns. The health insurance company must designate one or more qualified personnel to review the grievance and decide whether to reverse or uphold a denial. UNDERSTANDING THE CHART Filed Grievances: Number of grievances submitted to the health insurance company in Closed Grievances: Number of grievances the health insurance company resolved by the end of Grievances Upheld: Number of closed grievances where the health insurance company stood by its original decision and did not decide in favor of the member or provider. Reversed Grievances: Number of closed grievances where the health insurance company changed its initial decision and decided in favor of the member or provider. Reversal Rate: Percentage of reversals resulting from grievances (closed grievances decided in favor of the member or provider) divided by closed grievances. KEEP IN MIND A health insurance consumer should pay specific attention to a health insurance company that has a very high or very low reversal rate. Please note: There is no ideal reversal rate. A low reversal rate may indicate that the health insurance company s initial decisions are correct, so fewer decisions require reversal, but an unusually low reversal rate may indicate that the health insurance company does not give appropriate reconsideration to initial decisions. A high reversal rate may indicate that a health insurance company s grievance process is responsive to members and providers, but an unusually high reversal rate may indicate that the health insurance company s process for making initial decisions is flawed. The number of grievances filed may be higher for health insurance companies that actively promote the grievance process to members and providers

26 25 Grievances HMOs 2014 Data Source: DFS HMO Filed Grievances Closed Grievances 1 Reversed Grievances Grievances Upheld Reversal Rate (Percentage) Aetna Health Inc % Capital District Physicians Health Plan % Community Blue (Healthnow) % Empire HealthChoice HMO, Inc. 2,178 1, , % Excellus Health Plan % HIP Health Maintenance Organization 1,308 1, % Independent Health Association, Inc % MVP Health Plan, Inc % Oxford Health Plans (NY), Inc. 1,581 1, % UnitedHealthcare of New York, Inc % Total 6,321 5,924 2,554 3, % 1Closed grievances can exceed filed grievances in 2014 because closed grievances also include grievances filed prior to Plan intends to withdraw from New York s individual health insurance market effective December 31, 2015.

27 26 Grievances EPO/PPO Health Plans Data Source: DFS EPO/PPO Health Plan Filed Grievances Closed Grievances 2 Reversed Grievances Grievances Upheld Reversal Rate (Percentage) CDPHP Universal Benefits, Inc % Empire HealthChoice Assurance, Inc % Excellus Health Plan, Inc. 3 1,734 1, % Group Health Incorporated 3 1,709 1, , % Health Republic Insurance of New York, Corp. 6,801 4,554 2,405 2, % HealthNow New York Inc % HIP Insurance Company of New York % Independent Health Benefits Corporation % MVP Health Insurance Company % Oscar Insurance Corporation % Oxford Health Insurance, Inc. 3 4,850 4,856 1,321 3, % UnitedHealthcare Insurance Company of New York % Total 15,416 13,303 5,193 8, % 1The non-profit indemnity category was removed and replaced with an EPO/PPO category to better reflect the types of policies currently being issued. The EPO/PPO category includes plans previously in the non-profit indemnity category and some plans previously in the commercial category that offer an EPO or PPO product. 2Closed grievances can exceed filed grievances in 2014 because closed grievances also include grievances filed prior to Grievances and reversal rates include data from the health insurance company's EPO, PPO and commercial business.

28 27 Grievances Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Filed Grievances Closed Grievances Reversed Grievances Grievances Upheld Reversal Rate (Percentage) Aetna Life Insurance Company 2,3 3,407 3, , % American Family Life Assurance Company of New York % American Progressive Life and Health Insurance % BCS Insurance Company % Berkshire Life Insurance Company of America % CIGNA Health and Life Insurance Company % CIGNA Life Insurance Company of New York % Combined Life Insurance Company of New York % Delta Dental of New York, Inc % Dentcare Delivery Systems, Inc % Eastern Vision Service Plan, Inc % First Unum Life Insurance Company % Genworth Life Insurance Company of New York % Guardian Life Insurance Company of America % Hartford Life Insurance Company % HM Life Insurance Company of New York % John Hancock Life & Health Insurance Company % Liberty Life Assurance Company of Boston % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no grievances. 2Grievances and reversal rates include data from the health insurance company's EPO, PPO and commercial business. 3Plan intends to withdraw from New York s individual health insurance market effective December 31, Plan issues dental coverage only. 5Plan issues vision coverage only.

29 28 Grievances Commercial Health Insurance Companies 2014 Data Source: DFS Commercial Health Insurance Company 1 Filed Grievances Closed Grievances Reversed Grievances Grievances Upheld Reversal Rate (Percentage) Lincoln Life & Annuity Company of New York % Massachusetts Mutual Life Insurance Company % Metropolitan Life Insurance Company % MVP Health Services Corporation % National Union Fire Insurance Company of Pittsburgh, PA % New York Life Insurance Company % Nippon Life Insurance Company of America % Northwestern Mutual Life Insurance Company % Paul Revere Life Insurance Company % Principal Life Insurance Company % Prudential Insurance Company of America % ShelterPoint Life Insurance Company % Standard Life Insurance Company of New York % Standard Security Life Insurance Company of New York % Sun Life and Health Insurance Company % Transamerica Financial Life Insurance Company % United States Fire Insurance Company % Total 4,501 4,116 1,247 2, % 1Many commercial health insurance companies do not write traditional comprehensive health insurance products and therefore have no grievances. 2Plan issues dental coverage only.

30 29 Quality of Care and Service for Health Insurance Companies Access and Service MEASURE DESCRIPTIONS Rating of Health Plan: The percentage of members who responded 8, 9 or 10 (on a scale of 0 10, where 0 is the worst health plan possible and 10 is the best health plan possible) when asked, How would you rate your health plan? Getting Care Quickly: The percentage of members who responded that they usually or always : Get appointments for regular or routine care as soon as requested. Get care right away for an illness or injury. Getting Needed Care: The percentage of members who responded that they usually or always thought it was easy to get: Appointments with specialists. Care, tests or treatments they thought they needed. Rating of Overall Health Care: The percentage of members who responded 8, 9 or 10 (on a scale of 0 10, where 0 is the worst health care possible and 10 is the best health care possible) when asked, How would you rate all your health care? Members Seen by a Provider: The percentage of adult health insurance members who had an outpatient or preventive care visit within the past 3 years, as reported by the health insurance company. A higher score means more people who were enrolled in the health insurance company had a provider visit.

31 30 Access and Service HMOs 2014 Data Source: DOH UNDERSTANDING THE CHART The symbols in the chart show how each HMO compares to the average for all New York HMOs. HMOs with a performed better than the New York HMO average. Note: Symbols show statistically significant differences between each health insurance company s score and the New York average. Statistically significant means scores varied by more than could be accounted for by chance. When comparing plan rates, note that some plans have the same rate but a different symbol. This is because plan rates are based on the number of members, which can differ among plans, and how much a plan s rate differs from the New York average. HMO Performance Compared to the New York HMO Average Rating of Health Plan Getting Care Quickly Getting Needed Care Rating of Overall Health Care Members Seen by a Provider Ages NY HMO Average Ages Aetna Health Inc Capital District Physicians Health Plan Community Blue (HealthNow) Empire HealthChoice HMO, Inc Excellus (Univera Healthcare) Excellus BlueCross BlueShield HIP Health Maintenance Organization Independent Health Association, Inc MVP Health Plan, Inc Oxford Health Plans (NY), Inc Plan intends to withdraw from New York s individual health insurance market effective December 31, Includes data for HealthNow PPO membership. 3Includes data for Univera PPO membership. 4Includes data for Excellus BlueCross BlueShield PPO membership. Legend Higher than the NY HMO average. Lower than the NY HMO average. No symbol indicates that the average is not different from the NY HMO average.

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